Case discussion

14 Aug 2021 .

G.Akshara kruthi ,3 rd sem 
Under the guidance of Deepika mam.

Case of 30 yrs old female with abdominal distension and bilateral pedal edema . 
 30 yrs old women presented to the causality with the case scenario as : 

Chief  complaints :
* Abdominal distension since 4 months .
*Dyspnea since 4 months 
* Bilateral pedal edema since 4 months 
 
History of present illness :
Bilateral pedal edema resolved on its own 
H/o of nonproductive cough 1 month prior to her son's delivery .
 
History of past illness: 
Not a k/ c/o  HTN ,DM ,thyroid disorder 
No H/o CAD ,CVA .

Personal history : 
Married 
Occupation : coolie 
Appetite:  normal 
Non vegetarian 
Bowels : regular
Micturition : normal
No known allergies 
No addictions

Family history : 
No such complaints seen in family .
No history of Diabetes, Hypertension,TB, Asthma, CAD,CVD

Obstetric history :

Age at marriage : 18 yrs 
Gravida : 04 
Para : 04 
Still births : 0
No of living children : 04 
Post NVD of her son .she says her abdominal distension .


General examination :

Patient was conscious, coherent, co- operative. Well oriented to time, place and person.

 pallor - present 
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema 
VITALS-
TEMPERATURE-Afebrile
BP-100/60mm of hg
PR-78 BPM, regular 
GRBS : 88 mg%
Systemic examination : 

Cvs: 
  S1 ,S2 heard .

Respiratory system :
BAE : + 
Normal Vesicular Breath  Sounds  heard 

Per abdominal examination : 
Inspection:
Shape : distended 
Umbilicus : everted 

Percussion :
Liver : dullness present at right 5 th intercostal space 
Dull ness all over abdomen 

CNS : 
Speech : normal 
Neck stiffness : No 
Kerning's sign  : No
Cranial nerves - intact 
Reflexes : normal 
Gait : normal 
 
Investigations : 

ECG : 



Chest x ray PA view : 



USG abdomen : 



Hemogram : 

Hb : 10 .3 gm / dl 
TLC : 6800 cells / cu.mm 
Neutrophils : 65 %
Lymphocytes : 15 %
Eosinophils : 05 %
Monocytes : 05 % 
Basophils : 00 % 
Pcv : 31.7 vol % 
MCV : 81.7 
MCH : 26 
MCHC: 31.9
RDW/CV :14.5 
RDW/ SD :43.8 
RBC count : 3.88 millions / cu.mm 
Platelet : 1.40 lakhs / cu.mm 


Complete urine examination : 



2D echo : 

Ascitic fluid amylase : 



Erythrocytic sedimentation rate :
RFT : 


Urea : 15mg/dl
Creatinine : 0.6mg/dl
Sodium : 130mEq/dl
Potassium : 3.2mEq/l
Chloride : 100mEq/l

LFT:  

Total bilirubin : 0.67mg/dl
Direct bilirubin : 0.20mg/dl
SGOT : 15 IU/L
SGPT : 10IU/L
ALP : 246IU/L
Total protein : 7.0gm/dl
Albumin : 3.8gm/dl
A/G ratio : 0.78

APTT: 
37 sec

BT & CT: 
BT- 2min 30sec
CT- 5min 00sec

Blood sugar random: 
RBS- 117mg/dl

Ascitic fluid protein sugar
Sugar : 79mg/dl
Protein : 5.1g/dl
Ascitic fluid for LDH
LDH- 419 IU/L
Serology- negative 

Diagnosis : Ascites secondary to ? Intestinal TB  


 Treatment : 
 Tab . LASILACTONE  20 / 50 mg BD 
Tab .PAN 40 mg OD 
Daily weight of Abdomen growth measurement 
BP / PR / temp / spo 2 monitory 


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